Thursday, December 3, 2009

Breast cancer screening: A discussion with an expert

Daniel Kopans, MD

On November 16, 2009 the United States Preventive Services Task Force (USPSTF) released new guidelines on breast cancer screening which set off an intense debate within the medical community regarding the value of early breast cancer detection. These new guidelines run contrary to the accepted recommendations that women should have mammograms every year beginning at the age of 40. The USPSTF advised against screening women in their forties and would only support mammograms every two years for women ages 50-74.

Daniel Kopans, MD, is a pioneer in breast cancer detection, diagnosis and screening. He is the senior radiologist in the Breast Imaging Division of the Mass General Hospital Cancer Center and a professor of Radiology at Harvard Medical School, and is considered one of the world’s leading experts in this field. He has been a very outspoken advocate for the importance of early breast cancer detection by regular mammography screenings and says the new guidelines are not supported by documented research that show that early detection saves lives. He answers some of your questions here.

Q: What are your concerns regarding the latest USPSTF recommendations?

A: Actually, the USPSTF agrees that screening saves lives. They do not feel that, according to their calculations, enough lives are saved to justify the anxiety of having a mammogram and the fact that some women will be called back for additional evaluation and a few will have a needle biopsy so that they decided to make the decision for women in their forties by not allowing them access to screening. This is all the more astonishing because they also advise against women in their forties having a clinical breast examination and they don’t want women in their forties to be taught to examine themselves. These guidelines leave nothing for women in their forties. The USPSTF is telling women in their forties to wait until their cancer is so large that they cannot ignore it and then seek attention when it is incurable.

For women 50 and over, the USPSTF advises against screening every year and only support screening every two years. They freely admit that this will mean that lives that could be saved by screening will be lost, but they argue that it reduces the false positives.

These are astonishing guidelines that will set women’s health back twenty years and result in an increasing death rate from breast cancer.

Q: What are the advantages of regular breast cancer screenings for women over forty?

A: The USPSTF actually agrees that the most rigorous scientific studies prove that mammography screening saves lives beginning at the age of 40. Mammography screening began across the Country in the mid 1980’s. Prior to that time, the death rate (the percentage of women in the population dying each year) from breast cancer was unchanged going back 50 years. Soon after women began to be screened, the death rate began to fall. Since 1990, the death rate has decreased by 30%. This means that, as long as screening continues, 30% fewer women will die each year from breast cancer. This is not a victory over these cancers, but a major advance that the USPSTF wants to stop.

Q: I have no family history of breast cancer. Why do I need to be screened?

What many people do not realize is that most women who develop breast cancer have no family history or any other “risk factors”. In fact, depending on which risk factors you look at, 75%-90% of women who are diagnosed each year with breast cancer DO NOT have a family history or other risk factors. All women are at risk. If the USPSTF guidelines were followed, most women who will develop breast cancer would not be screened.

Q: What about women fifty and over?

A: The age of 50 is actually meaningless. The detection rate of breast cancer increases steadily with increasing age with no abrupt change at the age of fifty or any other age. The USPSTF simply grouped women by decade to make it appear that there was a sudden change at the age of 50 when there is none. They also admit in their review that screening women very two years instead of every year will mean that some lives will be lost, unnecessarily. This is another astonishing admission. We strongly recommend that women in this age group continue with yearly mammography.

Q: How do we know early screening and detection saves lives?

A: As noted earlier, when mammography screening is made available, the death rate from breast cancer decreases. The facts are that since regular mammography and screening protocols have been in place the death rate from breast cancer has decreased by 30% since 1990. This is a significant. Several large and reputable studies done in Sweden and the Netherlands support this data. In addition another study conducted by Mass General researchers and recently presented at the American Society of Clinical Oncology in August of 2009, showed of the Massachusetts breast cancer deaths from a 1990 to 1999, that nearly 75% of these deaths occurred in women who went unscreened while only 25% of deaths occurred in women who consistently had yearly mammograms.

Q: What is the take away for women who are confused by the mixed message on screening guidelines?

A: The USPSTF guidelines ignore the fact that mammography has and will continue to save tens of thousands of lives. The evidence is clear that by screening women annually beginning at the age of forty, has spared many women unnecessary deaths from breast cancer. Unlike the USPSTF which wants to take away from women the right to decide if they want to be screened, we believe that each woman should make the decision for herself. The USPSTF is now claiming that they really just wanted women to discuss these issues with their doctors. This is fine, but, primary care doctors do not have the time to understand the mammography screening data. They rely on reviews such as those by the USPSTF to summarize the information. The USPSTF has clearly not performed a thorough summary. If you are age 40 or over I would suggest that you have the following conversation with your doctor.


What do you suggest about mammography screening?

Your doctor:

Mammography screening is not perfect. It does not find all cancers and does not find all cancers early enough to cure, but when used by women beginning at the age of 40, it has been shown to markedly reduce the number who die from breast cancer and allows therapy to be more successful. The numbers vary, depending on your age, since the risk of breast cancer goes up steadily with increasing age. If 1000 women are screened, approximately 80 will be called back for additional evaluation. These are the false positive studies you heard about. Among these women a few extra pictures or an ultrasound will show that there is nothing to be concerned about in approximately 45 of the 80 women. In 20 of the 80 women the radiologist may want to have them return in 6 months just to be careful. This means that the risk of what they are seeing being cancer is less than 2%. In approximately 15 women they will recommend a biopsy, which is generally done today with a needle using local anesthesia for numbing. Approximately, 5 of these 15 women will be found to have breast cancer. Obviously, it is your decision, but I recommend that you have a mammogram every year.

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